EmailMeForm
City of Hickory
PO Box 398, Hickory NC 28603
Phone:
828-323-7466
Email:
ahollar@hickorync.gov
Check all that apply to this business:
socially disadvantaged individuals as defined by Federal Statute 15 U.S.C. 637
economically disadvantaged individuals as defined by Federal Statute 15 U.S.C. 637
African American
Hispanic
Asian
Native American
Female
Check all responses that apply to this business in that at least 51% of this firm is owned AND operated
REPORTING REQUIRMENTS
Please Select
*
Social Security Number
Federal Employer Identification Number
In order to comply with Internal Revenue Service (IRS) regulations, we are required to obtain the Social Security Number (SSN) or the Federal Employer Identification Number (FEI) to satisfy Form 1099 reporting requirements. Failure to provide this information may subject all payments to the 28% backup withholding as required by the IRS. Enter your number below and place a check by the type of business.
SSN
*
Type of Business (using SSN)
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Individual
Sole Proprietorship
FEI
*
Type of Business (using FEI)
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Partnership
Sole Proprietorship
Estate/Trust
Corporation
Sub S Corp
Tax Exempt Organization
Type of Business/Product:
*
E-Verify
*
Yes, this buisness has more than 25 employees in North Carolina
No
E-Verify Employers and their subcontractors doing business in the State of North Carolina and employing 25 or more employees in the state must comply with E-Verify. Does your company have 25 or more employees in the state?
POINT OF CONTACT
Firm Name
*
Address
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Street Address
City
State / Province / Region
Postal / Zip Code
Contact Person
*
First
Last
Phone
*
###
-
###
-
####
Email
*
REMITTANCE ADDRESS
Remittance
*
Same as above
Different
Contact Person
First
Last
Address
Street Address
City
State / Province / Region
Postal / Zip Code
Phone
###
-
###
-
####
Email
Is any owner or employee of this company an elected official or employee of the City of Hickory?
*
Yes
No
*
Enter the name of owner/employee and position in your company:
I certify that I am duly authorized to complete this form, that the minority or disadvantaged business information is correct, that the legal organization and tax identification number are correct and that I am not subject to backup withholding.
Title:
*
Signature
*
Clear
(Sign using the computer clicker. To start over, click on 'Clear')
File Upload (if needed)
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